Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mid-wilshire Health Care Cntr during CMS and state inspections, most recent first.
A resident who was cognitively intact and required assistance with daily activities was not provided the opportunity for their next of kin to participate in a care plan conference, despite facility policy and the resident's care plan indicating a preference for family involvement. Documentation did not show that the next of kin was invited or notified, resulting in the resident and their next of kin not being given their right to participate in care planning.
A resident with dementia and anxiety disorder was moved to different rooms multiple times without advance written notice or proper documentation, and the responsible party was not notified as required. Staff interviews revealed that notifications were made informally and not documented in the medical record, contrary to facility policy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
Two residents were involved in an incident where an allegation of employee-to-resident abuse was not reported to authorities or investigated in a timely manner, despite facility policy requiring immediate action. One resident, with intact cognition, filed a grievance on behalf of another with severe cognitive impairment, describing forceful care by a CNA that led to distress. The DON and Administrator did not report the incident as required, citing lack of physical harm and incomplete communication of the incident details.
The facility did not complete annual performance evaluations for two LVNs and three CNAs, including a Restorative Nursing Assistant, as required by policy. The DSD was unaware of the requirement and had not reviewed the policy, and the DON confirmed that evaluations were not performed or documented in the employee files.
The facility did not follow standardized recipes or portion sizes for pureed diets, resulting in multiple residents receiving alternative foods of incorrect texture and consistency instead of the planned menu items. The menu lacked inclusion of therapeutic and texture-modified diets, and staff did not have guidance on appropriate portions or recipes, as confirmed by dietary staff and the registered dietitian.
Surveyors found that kitchen staff failed to follow safe food storage and preparation practices, including thawing meat on the counter, not maintaining the ice machine in a sanitary condition, and storing multiple food items without proper labeling or dating. These actions were contrary to facility policy and staff knowledge, and were confirmed by interviews and record reviews.
A resident with severe cognitive impairment and multiple chronic conditions was found in bed with the call light out of reach, despite care plan and facility policy requiring it to be accessible. Staff confirmed the call light was not within reach and acknowledged the importance of proper placement for timely assistance.
A resident with a history of DKA and uncontrolled diabetes experienced repeated episodes of extremely high blood glucose, with readings exceeding the glucometer's measurable range. Nursing staff did not notify the physician or document these events as required by facility policy and professional standards, and inaccurately recorded 'HI' readings. The lack of communication and documentation resulted in a failure to provide care according to orders and standards of practice.
A resident with severe cognitive impairment and a g-tube for nutrition did not have their enteral feeding bag changed every 24 hours as required by facility policy. Staff confirmed the bag had been in use for two days, acknowledging the risk of infection and GI complications due to this lapse.
A resident with dementia and a high risk for falls was admitted without a comprehensive fall prevention care plan, contrary to facility policy. Despite a high Morse Fall Score, the resident was not adequately monitored, leading to a fall and a left femur fracture. Facility staff acknowledged the absence of a necessary care plan, which contributed to the incident.
A facility failed to prevent falls for a high-risk resident with dementia and a history of falls. Despite having a care plan, the resident experienced multiple falls due to ineffective interventions and lack of proper monitoring. The facility did not revise the care plan after each fall, leading to repeated incidents and injuries.
A resident reported that a CNA touched her private parts and forced her to touch his private area, causing significant psychological distress. The incident was confirmed by surveillance video, and the CNA was asked to leave the facility. The resident's account remained consistent when reported to staff and police.
The facility failed to ensure that a CNA had the appropriate abuse training, leading to an alleged sexual abuse incident involving a resident. The CNA did not attend any abuse training sessions, and there was no employee file to verify competencies. The resident reported inappropriate touching by the CNA, and surveillance footage corroborated the timeline. Facility staff confirmed that registry staff were not provided with formal abuse training, violating the facility's policy.
Failure to Involve Next of Kin in Care Planning
Penalty
Summary
The facility failed to include a resident's next of kin (NOK) in the care plan conference, despite the resident's care plan indicating a preference for family or significant other involvement. The resident, who was cognitively intact and required varying levels of assistance with daily activities due to diagnoses including heart failure and lack of coordination, attended the care conference. However, there was no documentation that the NOK was invited to participate, as required by the facility's policy and the resident's care plan preferences. Interviews and record reviews confirmed that while the NOK was reportedly invited and unable to attend due to work obligations, this was not documented in the resident's records. The facility's policies require prompt and accurate documentation of such events and emphasize the importance of involving residents' families or representatives in care planning. The lack of documentation and failure to ensure the NOK's participation resulted in the resident and their NOK not being given their right to participate in the care planning process.
Failure to Provide Advance Written Notice and Documentation for Room Changes
Penalty
Summary
The facility failed to honor a resident's right to receive advance written notice and proper documentation before room changes occurred. Specifically, a resident with dementia and anxiety disorder, who required varying levels of assistance with daily activities, was moved to different rooms on four separate occasions. On each occasion, the responsible party (RP) was not notified in advance, and no written notice was provided explaining the reason for the room change. Additionally, there was no documentation in the resident's medical record regarding the room changes or the notification of the RP. Interviews with facility staff revealed inconsistencies in the notification process. The director of staff development confirmed that the RP should have been notified and consent obtained prior to any room change, but could not find documentation to support this. The social worker stated that notifications were made via text messages and that she kept a binder for room changes, but admitted that written notices were not provided and that documentation in the medical record was lacking. The facility's own policy required advance notice and documentation of room changes, which was not followed in these instances.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to follow its abuse policy and procedures for two residents when an allegation of employee-to-resident abuse was not reported to the state licensing/certification office, police, or ombudsman, and the incident was not investigated in a timely manner. Resident 2, who had intact cognition and the capacity to make decisions, filed a grievance on behalf of Resident 3, who had severe cognitive impairment and was dependent on staff for most activities of daily living. The grievance described an incident in which a CNA allegedly proceeded forcefully with care despite the resident's refusal, resulting in the resident yelling and screaming in resistance. Interviews and record reviews revealed that the Director of Nursing acknowledged the grievance contained an allegation of abuse and should have been reported, but it was not, as there was no physical problem observed. The Administrator stated he was aware of the incident but was not informed of the specific details indicating forceful behavior, which would have prompted reporting. The facility's policy required immediate reporting of all alleged violations of abuse to appropriate authorities, but this procedure was not followed in this case.
Failure to Complete Annual Performance Evaluations for Staff
Penalty
Summary
The facility failed to ensure that five employees received annual performance evaluations as required by facility policy. During a review of employee files with the Director of Staff Development (DSD), it was found that performance evaluations for two LVNs and three CNAs, including one Restorative Nursing Assistant, had not been completed. The DSD stated she was unaware of the requirement for annual performance evaluations and had not reviewed the relevant facility policy. The Director of Nursing (DON) confirmed that annual performance evaluations were required and acknowledged that the current DSD had not been instructed to perform them. The facility's policy indicated that each employee should receive an annual performance evaluation, with documentation maintained in the human resources file.
Failure to Follow Standardized Recipes and Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to ensure that standardized recipes and portion sizes for the lunch menu were followed for residents on pureed diets. During observations, it was noted that twenty-three residents on pureed diets did not receive the pureed versions of the menu items listed for the regular diet, such as pureed soybean paste stew and fern salad. Instead, they were served alternative pureed foods like meat, rice, and beans. The pureed foods provided were of a thin, soupy consistency rather than the required homogenous, cohesive, pudding-like texture. Staff interviews revealed that the menu did not include therapeutic or texture-modified diets, nor did it specify standard portions or serving guides for these diets. The dietary supervisor acknowledged difficulties in preparing the Korean menu for pureed diets and admitted to using portion sizes from an old menu as a reference. Further interviews and observations confirmed that the registered dietitian had not reviewed the menu or provided in-service training to staff regarding texture-modified diets. The dietitian stated that residents on pureed diets should receive the same foods as those on regular diets, and that the menu should include all therapeutic and texture-modified diets with appropriate recipes and portion sizes. Facility policy reviews indicated that menus should include standardized recipes, nutrient analysis, and portion control, but these were not being followed for the pureed diet. As a result, residents on pureed diets were not receiving meals consistent with the planned menu or in the correct texture and portion, as required by facility policy.
Deficient Food Storage, Preparation, and Sanitation Practices Identified
Penalty
Summary
The facility failed to maintain safe and sanitary food storage and preparation practices in the kitchen. Surveyors observed frozen sliced pork thawing on the kitchen counter instead of in the refrigerator, contrary to both facility policy and staff knowledge, which require thawing in a refrigerator or by other approved methods. The staff member responsible for this acknowledged the error, stating the meat should not have been left on the counter. Additionally, the kitchen was understaffed at the time, with the Dietary Supervisor and another staff member performing multiple duties, including dishwashing and cooking. Further deficiencies were identified with the facility's ice machine, which was found to have pink residue inside the storage bin and on the baffle, indicating it was not maintained in a sanitary manner. The ice scoop was also overdue for cleaning. The Maintenance Supervisor admitted to not cleaning the ice machine on schedule and failing to use sanitizer as required by facility policy. Review of cleaning logs and policies confirmed that the ice machine should be cleaned regularly with a sanitizer solution, but this was not done as specified. Additional issues were found with the labeling and dating of food items in the refrigerators. Open milk gallons and individual cups of beverages were stored without open or use-by dates, and other items such as sliced cheese, kimchi, and previously cooked rice were also found without proper labeling or dating. Facility policies require all refrigerated, ready-to-eat foods to be labeled and dated, and leftovers to be discarded if not used within specified timeframes. The Dietary Supervisor confirmed that staff failed to follow these procedures, resulting in improper food storage and potential for foodborne illness.
Call Light Not Within Reach for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, Parkinson's disease, lack of coordination, and polyosteoarthritis, was found in bed with the call light not within reach. The resident required extensive assistance with bed mobility, dressing, toileting, personal hygiene, bathing, and transfers, as documented in the Annual Minimum Data Set. The resident's care plan specifically included an intervention to keep the call light within reach due to the risk of bedside rail entrapment. During an observation, the call light was seen hanging at the end of the bed, out of the resident's reach. A CNA present in the room confirmed the call light was not accessible and acknowledged the importance of its placement. Interviews with an LVN and the Director of Staff Development further confirmed that facility policy requires call lights to be within easy reach of residents to ensure timely assistance. A review of the facility's policy also supported this requirement.
Failure to Notify Physician and Document High Blood Glucose Readings in Diabetic Resident
Penalty
Summary
A resident with a history of diabetic ketoacidosis (DKA) and uncontrolled diabetes was admitted to the facility with diagnoses including unspecified acidosis and Type II diabetes with ketoacidosis. The resident's care plan included monitoring for signs and symptoms of hyperglycemia and hypoglycemia, administering diabetes medications as ordered, and reporting abnormal findings to the physician. Despite these interventions, the resident experienced multiple episodes of extremely high blood sugar, with readings over 500 mg/dL documented on at least 27 occasions over a two-month period. The blood glucose machine used by the facility could only register readings up to 599 mg/dL, displaying 'HI' for higher values, which occurred several times for this resident. Facility staff failed to notify the resident's physician about these consistently high blood sugar readings, and there was no documentation of physician contact or a change in the resident's condition related to these events. Interviews with nursing staff and supervisors confirmed that the physician was not informed of the high readings, and that documentation of communication and interventions was lacking. The facility's policy required staff to contact the provider for glucose values above certain thresholds or when the glucometer reading was too high, but this was not followed in practice. Additionally, staff inaccurately documented 'HI' readings from the glucometer as 599 mg/dL, rather than recording the actual result and following the manufacturer's instructions to contact a healthcare professional immediately. The resident's family was not made aware that the physician had not been contacted regarding the high blood sugar levels. The medical director and other staff acknowledged that the standard of practice was not followed, and that the lack of communication and documentation represented a failure to provide care in accordance with professional standards.
Failure to Change Enteral Feeding Bag Every 24 Hours
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, dysphagia, aphasia, dementia, and Parkinson's disease, who was dependent on a gastrostomy tube (g-tube) for nutrition, did not receive proper care in accordance with facility policy. The resident's enteral feeding bag, which was supposed to be changed every 24 hours per the facility's Enteral Feeding Via Pump Administration policy, was observed to have been in use for two days without being changed. The feeding bag was dated two days prior to the observation, and the feeding pump was turned off at the time of inspection. Interviews with facility staff confirmed that the feeding bag and tubing had not been changed as required, and staff acknowledged the risk of infection and gastrointestinal complications associated with this lapse. The facility's policy, as well as statements from the Director of Staff Development and a Licensed Vocational Nurse, indicated that the failure to change the feeding bag and tubing daily placed the resident at risk for adverse outcomes.
Failure to Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of falls and dementia, who was assessed as high risk for falls. Despite the facility's policy requiring a person-centered care plan to manage risk factors, no such plan was created for the resident upon admission. The resident's Morse Fall Score was 75, indicating a high risk for falls, yet there was no documentation of a fall prevention care plan or monitoring for the resident on the day following admission. On the second day after admission, the resident was found on the floor, complaining of pain, and was subsequently diagnosed with a left femur fracture at a General Acute Care Hospital. The facility's failure to frequently monitor the resident and anticipate their needs, as well as the absence of a fall prevention care plan, contributed to the incident. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that a care plan should have been developed and implemented to prevent such an occurrence. The facility's policies, including the Person Centered Plan of Care and Post Fall Management Program, emphasize the importance of developing and updating care plans to prevent falls and accommodate resident needs. However, these policies were not followed in the case of the resident, leading to a preventable fall and subsequent injury. The lack of a fall prevention care plan and inadequate monitoring were identified as deficiencies in the facility's care for the resident.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident with dementia, a history of multiple falls, and a high risk for falls received the necessary care and services to prevent accidents and falls. The facility did not implement its Fall Prevention Program policy and procedure to identify interventions related to the resident's specific risks and causes. Additionally, the facility did not evaluate the effectiveness of interventions and implement new ones to prevent repeated fall incidents after the resident fell on multiple occasions. The resident was not monitored for the behavior of trying to get out of bed without assistance as per the physician's order, leading to repeated falls and a laceration requiring hospital transfer. The resident was admitted with diagnoses including a history of falling, dementia, lack of coordination, and Alzheimer's disease. The resident's care plan included interventions such as monitoring whereabouts, helping with transfers and ambulation, providing proper fitting shoes, maintaining a safe environment, and keeping the call light within reach. Despite these interventions, the resident experienced multiple falls, including incidents where the resident was found on the floor after attempting to go to the bathroom without assistance. The facility's staff did not revise the care plan effectively after each fall, and the same interventions were repeatedly implemented without success. Interviews with facility staff revealed that the resident was forgetful, confused, and unable to walk independently. Staff acknowledged that the resident did not use the call light and often tried to get out of bed without assistance. The facility did not use a bed alarm, which could have alerted staff when the resident attempted to get out of bed. The Director of Nursing and other staff members admitted that the care plan interventions were not person-centered and were ineffective in preventing the resident's falls. The facility's policies and procedures required reassessment and revision of care plan interventions after each fall, but this was not done, leading to recurrent falls and injuries for the resident.
Failure to Protect Resident from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a Certified Nurse Assistant (CNA). The resident, who was cognitively intact and had medical decision-making capacity, reported that the CNA touched her private parts and forced her to touch his private area. This incident caused the resident significant psychological distress, including feelings of fear, shame, anxiety, and guilt. The resident initially reported the incident to a caregiver from home, who then informed the facility staff. The incident occurred during the 7 AM to 3 PM shift when the CNA was assigned to care for the resident. Surveillance video confirmed the CNA's presence in the resident's room during the reported time frame. The resident described the incident in detail, stating that the CNA touched her inappropriately and made her touch him, despite her saying 'no' multiple times. The resident was observed crying and tearful during interviews, expressing fear of seeing the CNA again and concern about potential repercussions for reporting the incident. The facility's staff, including the Social Services Director and Administrator, were informed of the incident and took immediate steps to ensure the resident's safety. The CNA was asked to leave the facility and was not allowed to return. The resident's account of the incident remained consistent when reported to various staff members and the police. The facility's policy on abuse and neglect prohibits such actions, and the incident was thoroughly documented and investigated by the facility staff.
Failure to Provide Abuse Training to CNA Leads to Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) 1 had the appropriate abuse training, which led to an incident of alleged sexual abuse involving a resident. CNA 1, who had been working at the facility for several months, did not attend any of the abuse training sessions provided by the facility. The facility's records confirmed that CNA 1 did not participate in multiple in-service training sessions on abuse prevention and reporting, and there was no employee file for CNA 1 to verify competencies or skill sets. The Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that registry staff, including CNA 1, were not provided with formal abuse training during their orientation at the facility, relying instead on the registry agency to provide such training. This lack of training was in direct violation of the facility's Abuse and Neglect Prohibition Policy, which mandates that all staff, including those from registry agencies, receive abuse prevention training during orientation and ongoing sessions at least annually. The incident in question involved Resident 1, who was cognitively intact and had medical decision-making capacity. Resident 1 reported that CNA 1 had touched her inappropriately and forced her to touch his private area during a routine change of her incontinent brief. Surveillance video footage corroborated the timeline of CNA 1's presence in Resident 1's room, although it did not capture the alleged abuse directly. Resident 1 was visibly distressed during the interview, describing the incident in detail and expressing fear and confusion about whom to report the incident to. The facility's records indicated that Resident 1's family and physician were notified of the incident. Interviews with facility staff, including the DSD, DON, and the Administrator, revealed a systemic failure to ensure that registry staff received the necessary abuse training. The facility's Master Staffing Agreement with the registry agency placed the responsibility for compliance with health regulations, including abuse prevention training, on the facility. Despite this, the facility did not provide formal abuse training to registry staff, creating a potential risk for abuse. The Administrator, who was also the abuse coordinator, acknowledged that all staff should be trained on abuse prevention and that the lack of training could lead to potential abuse incidents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pih Health Good Samaritan Hospital D/p Snf | 0.2 mi | — | 3 | 0 |
| Burlington Convalescent Hospital | 0.2 mi | — | 0 | 0 |
| Angels Nursing Health Center | 0.2 mi | — | 0 | 0 |
| Bonnie Brae Skilled Nursing | 0.3 mi | — | 8 | 0 |
| Westlake Convalescent Hospital | 0.4 mi | — | 4 | 0 |
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